November
8, 1999
The Honorable June Gibbs Brown
Inspector General
Department of Health and Human Services
Office of Inspector General
Attention: OIG-7-CPG
Room 5246
Cohen Building
330 Independence Avenue, SW
Washington, D.C. 20201
RE:
File Code: OIG-7-CPG; Office of Inspector General; Solicitation
of Information and Recommendations for Developing OIG
Compliance Program Guidance for Individual Physicians
and Small Group Practices
Dear Ms. Brown:
The American College of Cardiology (ACC) is a 24,000-member
non-profit professional medical society and teaching
institution whose purpose is to foster optimal cardiovascular
care and disease prevention through professional education,
promotion of research, and leadership in the development
of standards and formulation of health care policy.
The College represents more than 90 percent of the cardiologists
practicing in the United States.
We appreciate this opportunity to offer our comments
on the Office of Inspector General's (OIG) solicitation
of information and recommendations for developing OIG
compliance program guidance for individual physicians
and small group practices. While we appreciate the OIG's
interest in providing iclear direction and assistance
to physicians . . . who are interested in reducing and
eliminating the potential for fraud and abuse within
their practice,i we caution the OIG that there are other
steps which both OIG and the Health Care Financing Administration
(HCFA) must take to assist physicians and other providers
who wish to reduce and eliminate fraud and abuse within
Medicare and other Federal health care programs.
Such steps, discussed in more detail below, include
the adoption of national payment policies, the elimination
of contradictory language in the current coding and
procedures manual, creation of educational programs
to assist those involved in coding to be compliant,
the creation of audit standards that clearly define
the rationale used in determining medical necessity,
and the fostering of a cooperative attitude towards
physicians and providers in developing correct and appropriate
coding.
These steps, taken together, would begin to go a long
way to simplifying the myriad of laws, regulations,
guidances, and other policies with which health care
providers must comply. The ACC steadfastly believes
that the vast majority of physicians and other health
care providers wish to comply with the laws governing
their participation in Medicare and other Federal health
care programs, but compliance is made all but impossible
by the shear number and complexity of those laws and
regulations, not to mention the degree of latitude given
the carriers and intermediaries in enforcement. As a
practical matter, it may be impossible for any compliance
program guidance to ensure that physicians and other
providers are in compliance unless the OIG and HCFA
to bring consistency to Medicare and other programs.
Finally, the seven elements that the OIG considers necessary
for a comprehensive compliance program must be considered
in light of the resources and capabilities available
to individual physicians and small group practices.
The designation of a compliance officer, for example,
poses difficulties in a small or individual practice
which may consist of as few as three persons. Since
the compliance officer must be a person with a thorough
understanding of the complexities of the fraud and abuse
laws as well as the many rules and regulations relating
to coding itself, most small practices would have to
hire an additional person or send someone for extensive
additional training. Each of these options would increase
overhead expenses for the practice. Indeed, the OIG
has recognized that implementation of a compliance program
imay require significant additional resourcesi in previous
compliance program guidance directed at other segments
of the health care industry, such as third party medical
billing companies. As such, we urge the OIG to make
any compliance program guidance for individual physicians
and small group practices as administratively simple
as is possible.
In the pages that follow, we discuss each of these considerations
in more detail. If you should have further questions
on this issue, please contact the ACC's Regulatory and
Legal Affairs staff at 800-435-9203. Thank you for your
consideration of our comments on this important matter.
Sincerely,
Arthur Garson, Jr., M.D., M.P.H, F.A.C.C.
President
Comments to the Department of Health and Human Services'
Office of Inspector;
Solicitation of Information and Recommendations for
Developing OIG Compliance Program Guidance for Individual
Physicians and Small Group Practices;
File
Code: OIG-7-CPG
Submitted by the American College of Cardiology
_________________________________
- Implementation
of an ieffective compliance programi may be prohibitively
expensive. The expense of implementing a compliance
program with all seven elements for a small group
or single physician's practice is prohibitive n even
the OIG has noted that implementation of ian effective
compliance program requires a substantial commitment
of time, energy and resources.i Furthermore, given
that the OIG has admonished that i[s]uperficial programs
that simply purport to comply with the [seven] elements
. . . or programs hastily constructed and implemented
without appropriate ongoing monitoring will likely
be ineffective and could expose [the provider] to
greater liability than no program at all,i we urge
the OIG to consider the actual resources and capabilities
of individual physicians and small group practices
when designing its compliance program guidance.
Recommendations:
(a)
The OIG must provide detailed and specific direction
for individual physicians and small group practices
that can be easily and efficiently tailored to their
practices. Unlike the targets of previous guidances
issued by the OIG, individual physicians and small
group practices do not have the resources, either
in staff or dollars, to pour into a compliance program.
The OIG should make clear what it expects in as
much detail as is possible.
(b)
The OIG should inform physicians of methods for
staying abreast of fraud and abuse activities.
Educational programs, software, and other methods
of informing physicians of fraud and abuse activities
and methods of complying with the myriad of complex
laws and regulations should be made available
and the OIG should inform physicians of how to
incorporate these programs into their compliance
programs.
- There
are steps that the OIG and HCFA can take to make compliance
easier for physicians and other providers. Physicians
and other providers that participate in Medicare and
other Federal health care programs must comply with
a myriad of laws, regulations, guidance documents,
and other statements of policy and procedure. In some
instances, Congress authors complex legislation that
becomes law before the Administration has promulgated
implementing regulations, allowing for much ambiguity
in the interpretation and enforcement of the law by
lower level entities within the Administration. This
only adds to the lack of clarity which makes compliance
difficult.
Recommendations:
(a)
The implementation of national payment policies,
written in language that is specific enough to minimize
or prohibit contractor interpretation. Added
to the complexity of the laws and regulations with
which physicians must comply is contractor interpretation.
In some instances, the same Medicare carrier may
have different payment policies for two different
states. This type of inconsistency leads to significant
confusion, making compliance all the more difficult.
(b)
HCFA-approved coding courses designed to produce
graduates that can understand and apply the complex
Medicare coding and billing policies, as well
as HCFA-approved continuing education for billers/coders
and physicians and their staff. Most coders
learn through on-the-job training, which is only
as good as the original staff providing the training
and the staff at the insurer (commercial or government)
with whom they interact.
At present, we are not aware of any HCFA-approved
commercial consulting groups that offer advice
on billing, coding, and documentation and the
HCFA-approved online courses in fraud and abuse,
diagnosis and procedure coding, and evaluation
and management documentation are brief and very
general in scope. The course materials do not
address the complex issues of contractor-specific
payment policies, such as local medical review
policies, or contractor-specific claims submission
policies, for example. Furthermore, most Medicare
contractors do not offer classes in any of these
areas that address their specific expectations
and audit standards. Finally, information on billing
and coding is not given much emphasis in the training
of physicians and nurses.
(c)
HCFA should approve national Medicare/Medicaid
audit standards, including standard audit workpapers
and supplementary audit criteria, that clearly
define the rationale used in determining medical
necessity. As above, there is no uniformity
in the implementation of these policies at a national
level.
(d)
Both HCFA and the OIG should immediately seek
to move to a cooperative relationship with providers
rather than the current adversarial relationship
that has developed. Like HCFA and the OIG,
physicians wish to reduce wasteful fraud and abuse
in Medicare and other Federal health care programs.
We are concerned, however, that many of the initiatives
undertaken by HCFA and the OIG to achieve that
end are needlessly overzealous and threaten to
punish physicians and other providers for honest
billing mistakes. Furthermore, some of these initiatives
threaten to interfere with the doctor-patient
relationship by creating an atmosphere of mistrust
between a physician and his or her patient. Implementing
some of these changes would begin to change the
atmosphere that exists between HCFA and the OIG
and physicians.
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